Nokea
Nurse is caring for newly admitted client with history of falls. Which is priority action by nurse?
- A. Complete fall-risk assessment
- B. Educate client & family on fall risks
- C. Complete physical assessment
- D. Survey client's belongings
Correct Answer: A
Rationale: The correct answer is A, complete fall-risk assessment. This is the priority action because it helps identify specific risks the client faces, allowing for tailored interventions to prevent falls. Educating the client and family (B) is important but assessing risk comes first. Completing a physical assessment (C) is also important but not the priority in this case. Surveying belongings (D) is not as urgent as assessing the client's fall risk.
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Nursing instructor reviewing documentation with students. Which of the following legal guidelines should they follow when documenting in client record? (Select all that apply.)
- A. Cover errors with correction fluid, & write in correct info
- B. Put date & time on all entries
- C. Document objective data, leaving out opinions
- D. Use as many abbreviations as possible
- E. Wait until the end of shift to document
Correct Answer: B, C
Rationale: Correct Answer: B, C
Rationale:
B: Putting date & time on all entries is crucial for legal purposes to establish timeline of events.
C: Documenting objective data without opinions ensures accuracy and prevents subjective bias.
Summary:
A: Covering errors with correction fluid is not recommended as it can be seen as tampering with records.
D: Using excessive abbreviations can lead to misinterpretation and errors in documentation.
E: Waiting until the end of the shift to document can result in missing crucial information or delayed updates.
Nurse reviewing nutrition guidelines with parents of 11 yo. Which parent statement should indicate to nurse that they understand guidelines for school-age children?
- A. She wants to eat as much as us, but we're afraid she'll be overweight.
- B. She skips lunch sometimes but we figure it's okay as long as she has healthy breakfast & dinner.
- C. We limit fast food restaurant meals to 3x/week now
- D. We reward her school achievements with point system instead of pizza or ice cream
Correct Answer: D
Rationale: The correct answer is D because the parent's statement indicates an understanding of proper nutrition guidelines for school-age children. By rewarding school achievements with a point system instead of unhealthy foods like pizza or ice cream, the parent is promoting a positive relationship with food and reinforcing healthy eating habits. This approach encourages the child to focus on their achievements rather than using food as a reward, which aligns with recommended nutrition guidelines for school-age children.
Option A is incorrect as it focuses on weight concerns rather than nutrition guidelines. Option B is incorrect as skipping lunch is not a recommended practice for children's nutrition. Option C is incorrect as limiting fast food intake is a good practice, but it does not directly relate to understanding nutrition guidelines.
Nurse manager is reviewing care of client with seizures with nurses on unit. Which statements by nurse requires more instruction?
- A. I will place the client on his side
- B. I will go to the nurses' station for assistance
- C. I will administer meds as prescribed
- D. I will be prepared to insert an airway
Correct Answer: B
Rationale: The correct answer is B because leaving the client during a seizure to go to the nurses' station for assistance is unsafe. The nurse should stay with the client to ensure safety. A: Placing the client on their side helps prevent aspiration. C: Administering prescribed meds is appropriate. D: Being prepared to insert an airway is essential in case of respiratory compromise.
Nursing instructor is explaining various stages of lifespan to students. Nurse should offer which of following behaviors by young adult as example of accomplishing Erikson's tasks for psychosocial development during middle adulthood?
- A. "client evaluates his behavior after social interaction"
- B. client states he is learning to trust others
- C. client wishes to find meaningful relationships
- D. client expresses concerns about next generation
Correct Answer: D
Rationale: The correct answer is D because expressing concerns about the next generation aligns with Erikson's task of generativity vs. stagnation during middle adulthood. This stage involves contributing to the well-being of future generations. Choice A focuses on self-reflection, not generativity. Choice B refers to Erikson's trust vs. mistrust stage in infancy. Choice C relates to forming intimate relationships in young adulthood. This highlights the importance of understanding Erikson's psychosocial stages to identify appropriate behaviors.
Nurse has noticed several times in past week when another nurse on unit seemed drowsy & unable to focus. Today, she found nurse asleep in chair in break room when she was not on a break. Which of the following actions should nurse take?
- A. Remind nurse that safe client care is priority on unit
- B. Ask others on team whether they have seen same behavior
- C. Report observations to nurse manager on unit
- D. Conclude her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct answer is C: Report observations to nurse manager on unit. This is the best course of action as it prioritizes patient safety and addresses the potential risk of a drowsy and unfocused nurse providing care. Reporting to the nurse manager is important to ensure proper intervention and support for the drowsy nurse.
Choice A: Reminding the nurse of safe client care is important but does not address the root cause of the behavior.
Choice B: Asking others on the team may provide additional insights but does not address the immediate need to ensure patient safety.
Choice D: Concluding that the coworker's fatigue is not her problem to solve neglects the responsibility to advocate for patient safety.
Overall, choice C is the most appropriate action to take in this situation to address the potential risk to patient care.